Electronic Health Record (EHR) Incentive Program
The Electronic Health Record (EHR) Incentive Program is overseen by the Centers for Medicare & Medicaid Services (CMS) for physicians participating in the Medicare component and individual state Medicaid agencies for physicians participating in the Medicaid program. Similar to other quality reporting programs, the EHR Incentive Program uses payment incentives and payment adjustments to encourage the adoption, implementation and use of certified EHR technology. The American Recovery and Reinvestment Act created the EHR Incentive Program.
Under the program there are two categories of professionals: “Hospital-based eligible professionals” and “Eligible Professionals” (EPs). Hospital-based eligible professionals are not eligible to receive the incentive payments and are exempt from future penalties. To be deemed a hospital-based eligible professional, one needs to provide 90 percent or more of their covered services in a hospital inpatient or emergency room setting. CMS determines this by looking at the place of service codes (POS codes) on the codes a physician submits for payment under Medicare (POS code 21 for Inpatient Hospital and POS code 23 for Emergency Room - Hospital). The majority of anesthesiologists do not provide 90% or more of their covered services in the hospital inpatient or ER setting unless one exclusively does cardiac, transplant or critical care work. The majority of the codes submitted by anesthesiologists are for Outpatient Hospital (POS code 22) or Ambulatory Surgical Center (POS code 24).
A majority of anesthesiologists are deemed EPs and thus eligible to receive the incentive payments for demonstrating “meaningful use” of EHRs. Because anesthesiologists were not initially intended to be deemed EPs when the law was debated, many of the meaningful use requirements do not reflect the typical practice of anesthesiology, making it difficult for anesthesiologists to achieve meaningful use. Only a fraction of anesthesiologists have been able to meet Meaningful Use Stage 1 program requirements.
The Hardship Exemption
As a result of ASA’s advocacy efforts, CMS created a hardship exemption for anesthesiologists, which exempts anesthesiologists from payment penalties that will begin in 2015. The exemption recognizes the state of commercially available EHR technology for anesthesiologists, workflow challenges and the nature of the patient-anesthesiologist relationship. The exemption was granted as part of the Meaningful Use Stage 2 Final Rule in 2012.
The hardship exemption is automatically determined and annually based on a physician’s specialty designation under the Provider, Enrollment, Chain and Ownership System (PECOS). Physicians with the Anesthesiology specialty designation of “05” do not need to complete the hardship exemption form. CMS reserves the right to revisit this exemption at any point. ASA has and will continue to advocate that this important exemption be maintained.
Participating in the EHR Incentive Program
Anesthesiologists may attempt to become meaningful users and receive incentives, as the hardship exemption only applies to the penalties. CMS and the Office of the National Coordinator for Health Information Technology (ONC) have provided several resources for physicians seeking to participate in the EHR Incentive Program. To learn more about the program, physicians are encouraged to use the CMS eligibility tool and review the CMS-produced "Beginner's Guide". EPs must participate in meaningful use by 2014 to earn incentives under the Medicare program. The Medicaid EHR Incentive Program extends incentives to 2016.
ONC is the “principal federal entity charged with coordination of nationwide efforts to implement and use the most advanced health information technology and the electronic exchange of health information.” ONC supports “the adoption of health information technology” and promotes “nationwide health information exchange to improve health care.” The agency was established in 2004 and mandated through the Health Information Technology for Economic and Clinical Health Act (HITECH) in 2009. Similar to CMS, ONC is an agency under the Department of Health and Human Services and their participation in and support of various policy committees informs upon the direction and planning of meaningful use requirements within the EHR Incentive Program.
ONC provides physicians and practices with a variety of information on how to take the first steps toward implementing EHRs in your practice, achieving meaningful use and supporting the implementation of EHRs. ONC also supports educational efforts on HIT implementation and use of EHRs. In particular, ONC is hosting several meetings and webinars as part of Health IT Week (September 15 - 19, 2014).
ASA Regulatory and Legislative Action
ASA continues to advocate that the criteria to meet meaningful use be applicable to anesthesiologists. In 2013, ASA stressed the importance of maintaining the hardship exemption in comments submitted to the ONC Health IT Policy Committee regarding their recommendations for Meaningful Use Stage 3. ASA supported the Health IT Policy Committee's recommendation to exclude specialists from the prevention reminder objective and to exclude eligible professionals who do not administer immunizations from the immunization objective. ASA also recommended excluding anesthesiologists from other requirements, including the clinical summary requirement, syndromic surveillance, e-communication with patients and computerized order entry for transfers of care objectives. ASA expressed support for allowing reporting to a registry as a menu objective. ASA also recommended additional flexibility for physicians who achieve a close percentage of the objectives.
ASA has also worked with Representative Diane Black (TN-06) on legislation that, if enacted into law, would ease anesthesiologists’ participation in the EHR Incentive Program by exempting anesthesiologists from some of the criteria required to demonstrate meaningful use. Such criteria include exempting anesthesiologists from providing clinical summaries to patients, exempting anesthesiologists from being required to provide patients with an electronic copy of their health information and exempting anesthesiologists and other eligible professionals from implementing drug-to-drug and drug-to-allergy interaction checks.
ASA Statements and Comment Letters
July 21, 2014: ASA submitted comments regarding CMS proposed modifications to the Medicare and Medicaid EHR Incentive Programs for 2014. Many of the proposed provisions were finalized by CMS on August 28, 2014.
January 14, 2013: ASA Comment Letter to ONC Health IT Policy Committee regarding proposed criteria for Meaningful Use Stage 3.
May 7, 2012: ASA Comment Letter to CMS regarding the Meaningful Use Stage 2 proposed rule.
February 18, 2011: ASA sent a letter to the CMS Office of E-Health Standards & Services regarding to applicability of Meaningful Use Stage 1 criteria to common anesthesiologist practice sites.
December 15, 2010: ASA sent a joint letter with the American College of Radiology and the College of American Pathologists to CMS requesting consideration of the workplace environment and patient-physician relationship that may limit the ability of certain physicians to meet EHR Incentive Program requirements.
March 15, 2010: ASA submitted comments to CMS on the EHR Incentive Program Proposed Rule.
Meaningful Use Objectives and Criteria Resource
When the EHR Incentive Program was launched, ASA compiled a table linking individual Meaningful Use Stage 1 Objectives and Criteria with their applicability to the workplace environment that an anesthesiologist typically practices. Please note that slight changes have been made on several of the meaningful use objectives since the publication of this table.
Please direct your questions on the EHR Incentive Program to the ASA Quality and Regulatory Affairs (QRA) Department. QRA may be contacted at (202) 289-2222 or by e-mail at firstname.lastname@example.org.